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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609778
Report Date: 07/28/2025
Date Signed: 07/28/2025 06:54:36 PM

Document Has Been Signed on 07/28/2025 06:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:YOUR HOME ASSISTED LIVINGFACILITY NUMBER:
197609778
ADMINISTRATOR/
DIRECTOR:		AVETISYAN, ARMENUHIFACILITY TYPE:
740
ADDRESS:7022 MATILIJA AVENUETELEPHONE:
(818) 983-2224
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY: 6CENSUS: 4DATE:
07/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:54 AM
MET WITH:Armenuhi Avetisyan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
07:00 PM
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Licensing Program Analyst(LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool. LPA Yee was let into the home by Mirna Apkarian, Staff. Armenuhi Avetisyan, Administrator was contacted by telephone and she arrived at 11:16am to conduct the visit.

The facility is a single storey home consisting of a living room, dining room, kitchen, 3 resident bedrooms, 2 common bathrooms of which one is designated for staff use, a staff room and a attached garage. The home is fire cleared for 5 non-ambulatory and 1 bedridden. Bedroom # is approved for bedridden use.

On today's visit, LPA Yee reviewed all 12 domains of the CARE Inspection Tool, 4 residents files, 5 staff files and toured the physical plant, inside and outside and the following was observed:
  • the living room, dining room and kitchen were appropriately furnished and equipped. On today's visit the refrigerator in the kitchen was turned off to troubleshoot the excess ice in the freezer and may have to be replaced. Per the Administrator, the refrigerator just started acting up yesterday, 7/27/25 and is scheduled for an inspection from a repair person this evening to determine if it needs to be replaced. The water tested in the kitchen read 118.6 degrees Fahrenheit.
  • Sufficient perishable foods were observed in the garage refrigerator for 2 days and non-perishable foods for 7 days were observed in the hallway closet.
  • Bedroom #1, located in the front of the home is currently used as a private room and was observed with a hospital bed, 2 night stands, 2 lamps, a chair and a built in closet. No dresser was provided at the request of the resident. The bed linens were provided as per the resident's personal request.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/28/2025 06:54 PM - It Cannot Be Edited


Created By: Christine Yee On 07/28/2025 at 04:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: YOUR HOME ASSISTED LIVING
FACILITY NUMBER: 197609778

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(g)(8)(C)
Admission Agreements
(C) All policies concerning the retention or prohibition of firearms by residents of the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview with the Administrator, the licensee did not comply with the section cited above in all counts as the Admissions Agreement does not address the facility's policy on the retention or the prohibition of firearms, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2025
Plan of Correction
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The Licensee will ensure that the residents and their responsible parties are made aware of the facillity's policy on the retention or the prohibition of firearms in the facility. Licensee will submit an addendum to their Admission Agreement to address the facility's policy on the retention or prohibition of firearms to the Department for review by 8/4/25.
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above per tour of the physical plant, it was observed that the screen door on the sliding glass door was warped and not closing completely, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2025
Plan of Correction
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The Licensee will ensure that the screen door is replaced or fixed to ensure that the door is able to close tightly by 8/4/25
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2025


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: YOUR HOME ASSISTED LIVING
FACILITY NUMBER: 197609778
VISIT DATE: 07/28/2025
NARRATIVE
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  • Bedroom #2 located adjacent to the attached garage was observed with 2 hospital beds, 2 night stands, 2 lamps, a four drawer dresser, a chair and a built in closet. One of the beds in the room was vacant and the other bed had linens as personally requested by the resident-no flat sheets or comforters.
  • Bedroom #3 had 2 hospital beds 2 night stands, 2 lamps, 1 chair, no dressers at the request of the residents. A mattress cover, a fitted sheet and a blanket was observed. Flat sheet and comforter not observed on the beds as requested by the residents. Curtains need to be placed on the back window for privacy. The sliding glass door was equipped with an auditory device was operational. The warped screen door needs to be fixed to ensure that the door can be completely closed. The Licensee will rearrange the room to ensure that the beds are not blocking egress from the room in an emergency.
  • Flat sheets, blankets, bath towels and extra fitted sheets were observed in the linen closet located in the hallway.
  • The common bathroom, located by bedroom #2 was observed with a walk in shower, a toilet and a 2 sink vanity. Grab bars, a shower chair and a slip resistant mat was observed. The water temperature was tested and read 115.6 degrees Fahrenheit.
  • The front bathroom with a large bath tub, a shower stall and toilet was locked and designated for staff use.
  • The only fire extinguisher, purchased on 3/25/25 was mounted in the living room.
  • Medications are stored in a locked cabinet in the kitchen.
  • Cleaning solutions and disinfectants are stored in the garage and in a locked cabinet in the common bathroom.
  • The first aid kit was reviewed and contained a tweezer, scissors and an external thermometer. A first aid manual was also observed.
  • The hardwired smoke detectors located in all 3 bedrooms, one in the hallway and a combo smoke/carbon monoxide detector, also located in the hallway was tested and was operational.
  • The facility has current general liability insurance that meets Title 22 requirements of $1 million per occurrence and $3 million total annual aggregate.
  • a washer and dryer was observed in the locked garage.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: YOUR HOME ASSISTED LIVING
FACILITY NUMBER: 197609778
VISIT DATE: 07/28/2025
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  • No bodies of water were observed on the property.
  • Located in the back is a covered patio with a table and chairs.
  • The backyard and front yard were clean.
  • The trash cans located in the front were observed to be tightly sealed.


Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Any deficiencies not addressed on today visit will be addressed on a return visit.

Exit interview was conducted with Mirna Apkarian, Staff as the Administrator had to leave during the visit.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025
LIC809 (FAS) - (06/04)
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